Great Eastern Life Assurance (Malaysia) Berhad (93745-A)
Head Office: Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur Customer Service Careline: 1-300-1-300-88 Fax: (603) 4259 8000 E-mail: wecare-my@greateasternlife.com Website: www.greateasternlife.com ACCIDENT CLAIM FORM ATTENDING PHYSICIAN'S STATEMENT BORANG TUNTUTAN KEMALANGAN KENYATAAN DOKTOR YANG MERAWAT The medical fee is to be borned by the patient Yuran Laporan Perubatan akan ditanggung oleh pesakit 2. 3. 4. 5. 6. 7. 8. For NON - FRACTURE injuries Untuk kecederaan BUKAN PATAH Please state detailed injury {Type / Site / Size / Severity etc} Sila nyatakan butir-butir kecederaan {Jenis / Tempat / Saiz / Tahap dan lain-lain} 9. Were there any external and visible injuries or wound as a result of this accident. If No, Describe any other evidence that is consistent with the accident as claimed by the patient Adakah terdapat sebarang kecederaan / luka luaran ketara akibat kemalangan tersebut? Jika tidak, nyatakan sebarang bukti yang konsisten dengan kemalangan seperti yang dituntut oleh pesakit 10. For AMPUTATION injuries, please state level of amputation seen. Jika berlaku sebarang AMPUTASI anggota, sila nyatakan tahap amputasi tersebut (proximal, tengah, distal). 11. Treatment given including follow-up (Dates of consultation, healing progress, treatments such as physiotherapy, etc.) Rawatan yang diberi termasuk rawatan lanjutan (Tarikh rawatan, kadar sembuh, rawatan seperti jumlah jahitan, STO, fisioterapi, jenis pencucian dsb.) 12. For FRACTURE injuries Untuk kecederaan PATAH i) Location & Type of fracture Lokasi & Jenis patah ii) Method of fracture treatment employed Jika pesakit diberi sebarang bentuk pembatasan bergerak (POP, sendal belakang, crepe bandage, dan sebagainya) Sila nyatakan INJURY DETAILS BUTIR-BUTIR KECEDERAAN a) Date of commencement of medical leaves Tarikh cuti sakit bermula b) Date of expiry of medical leaves Tarikh cuti sakit berakhir c) Number of days of light duty Bilangan hari pesakit tugas ringan Describe in detail the nature of accident as related to you by the patient Terangkan secara terperinci jenis kemalangan seperti yang telah dinyatakan oleh pesakit Date & time of first consultation Tarikh & masa rawatan pertama Date & time of accident Tarikh & masa kemalangan Occupation Pekerjaan Age Umur Patient's name Nama Pesakit 1. PARTICULARS BUTIR-BUTIR Policy No. No. Polisi Policy No. No. Polisi Policy No. No. Polisi Policy No. No. Polisi Policy No. No. Polisi Name of Life Assured Nama Hayat yang Diasuranskan Old NRIC/BC/Passport No. No. KP Lama/Sijil Kelahiran/Paspot New NRIC No. No. KP Baru - - 2087251803 2087251803 2087251803 2087251803 a) Date first applied question 12(ii) and removed Tarikh mula digunakan soalan 12(ii) dan ditanggalkan b) Date patient started physiotherapy Tarikh pesakit mula fisioterapi c) Date patient started on partial weight bearing / full weight bearing Tarikh pesakit memulakan senaman tanpa sokongan / pembatasan pergerakan sebenar bagi sebarang anggota penyambung pada tarikh akhir rawatan 13. a) Last date of consultation Tarikh akhir rawatan b) Condition and Function of the injured part on discharge Keadaan anggota yang cedera For complications of injury. Give details of complication, severity and its management. Adakah proses sembuh lancar/rumit? Sila beri butir kerumitan 14. 15. Kindly furnish report of X-rays and other imaging films done. Include report of latest films on discharge. Adakah gambar sinar X diambil? Jika ada, sila sertakan laporan / filem sinar X 16. Details of Hospitalisation Butir Kemasukan Hospital a) Name of hospitalisation Nama hospital b) Admission No. No. Pendaftaran c) Date admitted Tarikh masuk d) Date discharge Tarikh keluar e) Date surgery performed Tarikh pembedahan dilakukan f) Details of surgery / other special diagnostic procedure or treatment. Butir pembedahan / lain-lain prosedur diagnosis atau rawatan khusus 17. Name and address of other doctors who treated Patient for the same injury. Nama dan alamat doktor-doktor lain yang merawat Pesakit untuk kecederaan yang sama 18. In your opinion, is there any existing physical impairment or disease / illness which may have contributed directly or indirectly to the accident? Pada pendapat anda, adakah terdapat kecacatan fizikal atau penyakit yang mungkin menyumbang secara langsung atau tidak langsung terhadap kemalangan ini? I hereby certify that the above answers are all true to my best knowledge. Saya dengan ini mengesahkan bahawa semua jawapan di atas adalah benar setakat pengetahuan saya.
Date Tarikh Note NOTA: Medical Practitioner or Doctor shall mean a Surgeon or Physician qualified by degree in Western Medicine, who is legally licensed and duly qualified to practice medicine and surgery authorized in the geographical area of his practice and who also possesses a current Annual Practicing Certificate Pegawai Perubatan atau Doktor ialah seorang pakar bedah atau doktor yang layak dan berijazah dalam perubatan barat. Dia hendaklah menpunyai lesen secara sah di dalam kawasan geografi yang dipraktisnya dan mempunyai Sijil Praktis Tahunan yang terkini.
Signature of doctor Tandatangan doktor Name & Practice stamp Cop Nama & Amalan Name & address of hospital / clinic Nama & Alamat hospital / klinik HOSPITALISATION HOSPITAL 6021251805 6021251805 6021251805 6021251805